Recently I received a question regarding the use of the risk assessment process to determine whether an environmental condition was being appropriately managed. During survey, these folks were cited for not actively monitoring temperature and humidity in a sterile storage supply room adjacent to the OB surgical procedure room (this is one location that I’ve seen cropping up in recent surveys—please remember to keep an eye on sterile storage locations). The physical layout of the space, including the HVAC equipment, basically provides the “same” environment for the procedure room (where they had been monitoring humidity and temperature), so the question became whether the risk assessment process could be used to indicate that if the temp and humidity in the procedure room had been fine, then the sterile storage room would be fine as well.

Now if we’d been having this discussion prior to the survey finding, we might have had a little bit of leverage, but I still think it would be a tough sell, both during survey or as part of the clarification process, because up to this point, there was no performance data to support that determination (which doesn’t mean it isn’t the case, just means there’s no supporting data—a very important and useful thing to have). My advice, especially since they’d taken the hit during survey, was to collect data for 12 months (this particular facility is located in an area that has four seasons—if you’re looking at a similar situation, but you only have, say, two seasons, you might be able to get away with fewer than 12 months of data) and then make the determination that monitoring only need be occurring in one location in this space. As an additional protective measure, I also suggested they might consider submitting data to the folks at the Joint Commission Standards Interpretation Group and query whether the consistency of data supports the monitoring conditions in the entire suite and not having to monitor in each space. Surveyors are more frequently arriving with past survey results, so it’s important to make sure you are appropriate and consistently managing past findings—you don’t want to be in a position in which previously noted conditions have not been corrected.

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About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.